Healthcare Provider Details

I. General information

NPI: 1457896508
Provider Name (Legal Business Name): BRITTANY ROBERTS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2016
Last Update Date: 12/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2303 PARKE AVENUE
BURLEY ID
83318
US

IV. Provider business mailing address

225 FALLS AVE W APT 214
TWIN FALLS ID
83301-2600
US

V. Phone/Fax

Practice location:
  • Phone: 208-677-3073
  • Fax: 208-677-3181
Mailing address:
  • Phone: 208-869-1020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number3528
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: